Provider Demographics
NPI:1093449134
Name:RIVERA, MARC-ANTHONY
Entity Type:Individual
Prefix:
First Name:MARC-ANTHONY
Middle Name:
Last Name:RIVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5197 NW LOWER RIVER RD.
Mailing Address - Street 2:#1
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-1678
Mailing Address - Country:US
Mailing Address - Phone:626-825-4180
Mailing Address - Fax:
Practice Address - Street 1:5197 NW LOWER RIVER RD.
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660
Practice Address - Country:US
Practice Address - Phone:360-205-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty